Murphy Jr., James Edward E-
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Raymond Martin Hollis Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/10/2019 77 Years War or Dates 1959-1963
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Mannerof Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
El
(W) Circumstances Investigation
GMedical Certifier Name Title
Matthew Loftus PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 530
Burial Date Cemetery,Crematory or Facility Name
12/11/2019 Pine View Crematory
Entombment Address
unj Cremation Queensbury Town,New York
❑Donation
OZ Removal Date Place Removed
and/or and/or Held
N
( Hold Address
O
a Transportation Date Point of
N �
p by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
IDReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
II— Remains are Shipped,If Other than Above
Address
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/11/2019 Registrar of Vital Statistics 9&Aert lrrdiewC rtis(EYectrnnicaf Srgwd)
(signature/
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition JZ ►2 h I Place of Disposition
W
2 (address)
W
N (section/ (lot number) (grave number)
SName of Sexton or Person in Charge of Premis ^1
Z (pi ase print)
Hi Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013146
6
Receipt
Human remains of �_ _,tiR, f`"� ;f. i ( delivered on ?,` - % , 20
Pine View Cemetery Repres�tipfig the funeral home named on burial permit
Official Funeral Directors Reg.or License#,41(